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PLASMA CELL
DYCRASIAS
Dr. Raziya Mia
Dr. Heather Sutherland
Monoclonal Gammopathy of
Unknown Significance (MGUS)
MGUS Criteria
Monoclonal Protein < 30 g/L
Clonal Bone Marrow Plasma Cells < 10%
No end organ damage:
C = Hypercalcemia: 0.25 mmol/L > ULN
R = Renal Insufficiency: CrCl < 40 ml/min
A = Anemia: < 2 g/L below LLN
B = Bone Lesions: 1 or > oseolytic lesions
MGUS Facts
Prevalence: 3.2% in the general
population 50 years of age and older
Generally asymptomatic
Multiple Myeloma evolves from MGUS
1% of MGUS/year will develop into active
myeloma
Only 10% of new Multiple Myeloma has a
previous history of MGUS
Mr. MS
Follow up arranged for periodic monitoring
Any other recommendations?
Vaccinations
As per age
Travel
Seasonal Influenza
Pneumococcal
Zostavax
Mr. MS June 2017
Remains well, active, and asymptomatic
BP well controlled on Amlodipine
Mr. MS - Investigations
Hgb 137 g/L, WBC 13, ANC 8.5, Lymphocytes
2.8, Monocytes 1.4, Platelets 316
Creatinine 94 umol/L, CrCl 83 ml/min
Calcium 2.30 mmol/L
SPEP: IgG Kappa Band 33g/L
Normal SFLC
Free Kappa LC 11.6 mg/L
Free Lambda LC 5.6 mg/L
Bone Marrow Biopsy
24% Plasma Cells
Kappa Clonal Population
Mr. MS June 2017
Next recommendation?
Ms. GR – Add Pamidronate
MYPAM – Pamidronate
Dose: 30 mg IV once monthly
Contraindicated if CrCl < 30 ml/min
Dental evaluation prior to use (even if edentulous!)
Can cause symptomatic hypocalcemia
Avoid other calcium lowering agents such as loop diuretics
SCT Eligible
Monthly until complete/very good partial response or x 24
months
SCT Ineligible
From initiation of systemic Rx x 24 months
Restart after relapse Rx x 24 months
Ms. GR completes 9 cycles of
CyBorD - Feb 2017
Recommendations following
Stem Cell Transplant?
Post SCT
Valacyclovir prophylaxis x1 year
CT Scan
Cord compression at T7 – T8
5mm space within which the cord travels
Ms. JV - Management
Urgent BCCA Consult requested
Following radiation oncologist &
neurosurgeon discussion, decision is to
proceed with radiation first.
Started on Dexamethasone
What dose would you prescribe?
More Steroid is Not Better!
Dexamethasone 16 mg daily
Studies show no difference with high dose
(100 mg daily) in back pain relief, ambulatory
capacity, and survival.
High dose associated with increased adverse
events such as:
Sepsis
Hypomania
Psychosis and confusion
Gastric perforation
Ms. JV - Treatment
XRT: Dec 12-17, 2008 – T7 with margin.
Direct posterior field, 20 Gy in 5 fractions
Ms. JV - Investigations
Hemoglobin 121 g/L, WBC 8.7, platelets 256
Creatinine 60 umol/L
Calcium 2.28 mmol/L
LFT’S normal, LD 157 U/L
SPEP: 10 g/L monoclonal IgG kappa protein
SFLC
Free Kappa LC 90.4 mg/L
Free Lambda LC 10.2 mg/L
Ratio 8.86
Beta 2 microglobulin 1.3 mg/L
Ms. JV - Investigations
Bone Marrow biopsy
Myeloma with 15% plasma cells
Cytogenetics: 13q deletion
CT guided needle core biopsy of T8
Consistent with plasma cell neoplasm
MRI – Dec 29, 2008
Pathologic compression # of T7
Spinal stenosis less prominent than on pre-Rx CT
Skeletal Survey
Suspicious skull lesions, compression # T7, and
degenerative changes
Ms. JV - Treatment
Vertebroplasty in January 2009
Assessed by medical oncology and starts
Dexamethasone in VAD dosing
40 mg daily days 1-4, 9-12, 17-20 for 3 cycles
Monthly intravenous Pamidronate x 2 years
March 2009
Monoclonal band 2.3 g/L
Free Kappa LC 6.1 mg/L
Repeat Bone Marrow Biopsy shows minimal residual
disease
Autologous stem cell transplant – April 1, 2009
Ms. JV – July 2013
No myeloma symptoms
Gradual increase in
Paraprotein 12 g/L
Free Kappa Light Chain 55.4 mg/L
K/L ratio 5.38
Patient Resource
Myeloma Canada
https://www.myelomacanada.ca/